Oesophageal carcinoma in a married couple following long-term exposure to dry cleaning agents
- Correspondence to Professor T N Walsh, Department of Surgery, Academic Centre, Connolly Hospital, Blanchardstown, Dublin-15, Ireland;
- Accepted 9 November 2011
- Published Online First 6 December 2011
Occupational exposure to environmental carcinogens is a risk factor for the development of carcinoma of a number of organs. We report the case of a married couple, both of whom developed oesophageal squamous cell carcinoma (oSCC) following occupational exposure to perchloroethylene (PERC) over a 30-year period.
Idiopathic oSCC is not uncommon, but when it occurs in a husband and wife who worked in, and lived above, their own dry cleaning business, an active dry cleaning agent must be considered as the potential aetiological factor.
A 65-year-old man presented with a 6-month history of dyspepsia and epigastric pain without dysphagia or weight loss. He owned a dry cleaning shop and lived in the same premises for 30 years. He smoked a pipe for 35 years. Upper gastrointestinal endoscopy showed an oesophageal tumour at 33 cm, and staging CT confirmed lower oesophageal tumour without evidence of lymphadenopathy or distant metastasis. He underwent transhiatal oesophagectomy and the final histopathology confirmed oSCC.
Two years later, a 70-year-old woman (wife of the above patient) presented with a 3-month history of dysphagia for solids associated with a weight loss of 14 pounds, fatigue and hiccups. She worked in the same dry cleaning shop and lived with him at the same site. She was a lifelong non-smoker, social drinker for 10 years and ate a balanced, non-restricted diet. Upper gastrointestinal endoscopy showed an oesophageal tumour extending from 23 to 30 cm and staging imaging confirmed a localised lower oesophageal tumour. The patient was treated with neoadjuvant chemoradiotherapy prior to oesophagectomy. Final histopathological examination confirmed well-differentiated keratinising oSCC.
Both patients were exposed to PERC while loading clothes into the machines, removing clothes before the drying cycle is finished, transferring solvent-laden clothes into the dryer, and during cleaning and maintenance of the machines. PERC is a volatile organic solvent used in the dry cleaning process which has hitherto attracted attention as a potential carcinogen.1
The International Agency for Research on Cancer classifies PERC as a probable human carcinogen, associating exposure to PERC with increased risk of oSCC in its evaluation of epidemiological studies. Studies of PERC levels in apartments or homes located near dry cleaning shops reported the residents' exposure to PERC as considerable.2–5 PERC in domestic alveolar-air samples suggests non-occupational exposure to PERC for family members of dry cleaners, while the serum concentration of PERC was dependent on the proximity of subjects to a dry cleaning shop, and not necessarily to the dry cleaning system itself.
Excess cancer mortality from aerodigestive tumours was shown after exposure to PERC in a cohort of 1704 dry cleaning workers, while other epidemiological studies support the association between PERC and oSCC.3
The married couple in this report who worked together in the same dry cleaning shop for 30 years fulfil the criteria for long-standing exposure to PERC, which supports its role as a potential risk factor for the development of oSCC.
This evidence suggests that all workers in the dry cleaning industry should have their PERC exposure levels monitored and that all persons with potentially toxic levels should be removed from risk.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.